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Yes, it’s possible that ADHD can be misdiagnosed as autism and vise versa, particularly if the type of ADHD diagnosed is the inattentive type (click here for my ADHD blog). Oftentimes there are a lot of ADHD symptoms that are mistaken as autism symptoms and autism symptoms can be mistaken as ADHD.

Huh? Are you kidding?

Seriously, it can happen to a lot of neurodiverse children. This ADHD/autism overlap is a controversial topic. It often confuses both the medical and scientific fields especially ordinary people (like me, I can relate to this). First, let’s see why ADHD and autism are often interchanged.

ADHD is a neurodiversity condition where the person who has this has really short attention span, is hyperactive, impulsive, or inattentive and can easily loss track of concentration. Autism, on the other hand, is a neurodiverse condition characterised by lack of social skills, lack of communication skills, or is obsessive with repetitiveness.

Clearly different set of symptoms, right? But a lot of people with autism especially children are seen as hyperactive and impulsive, making them prone to be diagnosed as ADHD instead. At the same time, people with ADHD have no classic symptoms of hyperactivity and impulsive behaviour; instead they withdraw into their wide world of imagination and/or having hyperfocus on area of interest, thereby mistaken as autism (that really happened to me in my toddlerhood when I was without social interaction, poor communication and lack of eye contact, I was mistaken to have autism-like symptoms until I was diagnosed with ADHD in college). This could be really confusing…

Image courtesy of Patheos. ADHD and autism symptoms can be confusing to diagnose.

But really, how can you tell if it is ADHD or is it autism?

Both disorders may affect sufferers’ social interactions, their ability to follow directions, and to stay focused. But neither autism nor ADHD has one symptom that makes making a diagnosis easy. Both disorders display a combination of symptoms, and thus a professional evaluation is necessary to clarify whether someone suffers from autism or ADHD.[1]

But even professionals are confused with the ADHD autism diagnosis.

There may be a reason why symptoms of ADHD and autism can be difficult to parse. Both can occur at the same time. A doctor may decide only one of the disorders is primarily responsible for your child’s symptoms. Not every child can be so clearly diagnosed, however. In those cases, kids with either ADHD or autism may actually have both conditions.[2]

Unfortunately, many doctors were hesitant to diagnose one child with both ADHD and autism for many years. For that reason, very few medical studies have looked at the impact of the combination of conditions on children and adults.[2]

Doctors are either too afraid of diagnosing a person with two neurodiverse conditions or others have mindset that thinks that having both ADHD and autism is impossible. For many years, the American Psychiatric Association (APA) stated that the two conditions could not be diagnosed in the same person.

However, in 2013, the Association changed its stance. In the “Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition” (DSM-5), the APA states that the two conditions can co-occur. The APA notes that doctors should also consider the possibility of a separate disorder that might account for all of the behaviors.[2]

But what causes difficulty in the autism ADHD misdiagnosis?

There are many reasons for the two conditions being confused in young children. Many children with autism display signs of hyperactivity and inattention when they start school. However, experts are very clear that as the child becomes older the apparent similarities between the two conditions will separate out. The child with autism may become more withdrawn and given the right environment their hyperactivity should wane and their difficulties with social skills will emerge. Children with ADHD on the other hand are unlikely to become calmer with age unless they receive medication or high-quality therapeutic interventions.[3]

But there is a bottom line of comparing ADHD with autism: Children with ADHD still develop social and communication skills and are unlikely to have the anxiety levels of a child with autism[3], who are struggling more with social and communication difficulties. People with ADHD are more social and communicative than people on the autism spectrum. Communication and social skill levels are what sets ADHD from autism.

In a nutshell, ADHD and autism can share many characteristics as well as differences, yet they are still two different neurodiverse conditions. They may or may not occur together.

Similarities between ADHD and autism[4]:

Inattention

Hyperactivity

Impulsivity

Sensory Processing Difficulties – people with ADHD and autism can have sensory processing disorder

Behavior Problems

Impaired Social Skills

Differences between autism and ADHD[4]:

Communication skills are usually more impaired with an autistic child

Children with autism or Asperger’s Syndrome may lack “theory of mind.” – theory of mind is the ability to attribute mental states — beliefs, intents, desires, pretending, knowledge, etc. — to oneself and others and to understand that others have beliefs, desires, intentions, and perspectives that are different from one’s own.[5] People with ADHD can have deficient theory of mind as well, but usually people on the autism spectrum have more severe deficit in theory of mind.

Children with ADHD are usually more capable of engaging and connecting with others.

But ADHD has some autistic-like traits like in this following research[6]:

Children with attention-deficit hyperactivity disorder (ADHD) often exhibit autistic traits, which can lead to even greater problems with socialization, according to new research presented at the 26th European College of Neuropsychopharmacology (ECNP) Congress.

Previous research has shown that children with autism spectrum disorder (ASD) often also have a diagnosis of ADHD. This new study suggests that the reverse may also be true.

“We showed that some children who do not fulfill the criteria for autism have a lot of similar social difficulties and interpersonal dysfunction. That might be something that’s important to recognize,” said lead researcher Joseph Biederman, M.D.

“We have been aware for a long time that some of those with ADHD have behaviors that look differently than what you would expect. They do not have a lot of social wisdom and have difficulties interacting, even though they do not fulfill criteria for autism,” said Biederman.

The ADHD-AT subgroup also had much higher rates of social dysfunction compared with the healthy control group and compared with the ADHD-only subgroup; and they had significantly higher rates of severe emotional problems.[6]

In addition, the ADHD-AT subgroup had significantly more disruptive behavior, mood, multiple anxiety, and language disorders than did either of the other groups.[6]

This is an ongoing research where there are a subgroup of children with combined autism-ADHD. This could be a milestone in neurodiversity as there are a lot of possibilities when it comes to the neurodiverse brain.

By properly identifying the similarities and differences in autism and ADHD, a professional, a teacher, a parent, or even you can identify who has ADHD and who has autism, or if a person has both ADHD and autism.

When a person has an autism spectrum disorder (ASD), he/she has significant impairment in the social world and chaos. He/she loves routine more and think more linear than the rest of us. This implies that he/she will struggle a lot in the workplace, especially if he/she’s nonverbal. But no worries. With proper assessment and identification of strengths and weaknesses, job hunting will be less difficult for him/her.

Here, I listed some of the more suitable jobs for people with ASDs. Most of them have the characteristic of routine, linear analysis, facts, long-term memory, and less people interaction. Researches from Indiana University suggested the following jobs as ideal for the person on the spectrum.

Notice all of these are categorized under physical sciences, computer, music, and art, as well as labor with no or limited need for constant communication – all these jobs are a perfect niche for the ASD person thanks to very strong analytical and linear thinking. In fact, some of these jobs do really prefer ASD folks over neurotypical (NT) people, like in computer sciences.

Now, the following jobs are NOT suitable for ASD people. I typed not all caps because the following jobs listed below demand a LOT of social communication that if an ASD person will work such jobs, he/she will be jeopardized as well as his/her colleagues, superiors, and companies that will only make the ASD person end up laid off or fired leaving him/her devastated and incompetent.

Worst Jobs for Adults with Autism[1]:

Cashier

Cook

Waiter/waitress

Casino dealer

Anything with oral dictation

Taxi dispatcher

Ticket agent (airline, circus, etc.)

Market Trader

Auctioneer

Receptionist

Image courtesy of Twitter. Secretarial jobs are hell for the autistic employee.

These jobs DO DEMAND for constant communication, multitasking, working memory and less analytical skills. These are considered hell for the ASD person as he/she cannot easily communicate ideas to other people, making him/her look incompetent, absent-minded, or a liar to other people, risking his/her credibility or professional standing.

Nurse – I’m totally related to this. Lots of communication, from doctors, health personnel, to patients and families, as well as quick common sense and working memory, multitasking. Very bad job and can cause burnout as well as well as risking your license and patients’ lives.

Secretary – another bad job. Constant communication (and flirting) with your boss and colleagues involving working memory and multitasking as well. Not good.

Temple Grandin gave also tips on employment when someone is on the spectrum.[2] She stated that ASD people have poorer working (short-term) memory – meaning getting and following verbal instructions right away – than most NTs. On the other hand, ASD people have stronger long-term memory than NTs, making ASD folks very good analysts, researchers, scientists, musicians, and artists.

Here is an excerpt from her article:

Some job tips for people with autism or Asperger’s syndrome:

Jobs should have a well-defined goal or endpoint.

Sell your work, not your personality. Make a portfolio of your work.

The boss must recognize your social limitations.

It is important that high functioning autistics and Asperger’s syndrome people pick a college major in an area where they can get jobs. Computer science is a good choice because it is very likely that many of the best programmers have either Asperger’s syndrome or some of its traits. Other good majors are: accounting, engineering, library science, and art with an emphasis on commercial art and drafting. Majors in history, political science, business, English or pure math should be avoided. However, one could major in library science with a minor in history, but the library science degree makes it easier to get a good job.

Miss Grandin’s right. An ASD person’s work and not speech should be emphasized in order for him/her to have a long-term job. Most of all, the employer should be very well aware of the autism spectrum, including its strengths and weakesses, and the employer must be supportive of his autistic employee (well, I guess it’s not that working well enough in my country…)

With these tips, there will be more hope for people with ASD to find meaning in their lives by their careers.

You hear it. You read it. Executive functioning, which is almost always broken in ADHD or autism and other developmental disorders and learning disabilities. Ever wonder what is executive functioning? What is executive functioning?

Executive function consists of several mental skills that help the brain organize and act on information. These skills enable people to plan, organize, remember things, prioritize, pay attention and get started on tasks. They also help people use information and experiences from the past to solve current problems.[5]

In short, executive function is comparable to a company’s CEO, a celebrity’s manager, a sport team’s coach, the film’s director, an orchestra’s conductor, or a computer’s CPU; all of them direct what a group or a person will do to make a group run smoothly.

Image courtesy of Balboa School. The brain’s executive function is comparable to a computer’s CPU.

There are 8 key executive functions in the brain according to Understood.[6] What are they?

Eight Key Executive Functions:

Impulse Control – helps your child think before acting.

Emotional Control – helps you child keep his feelings in check.

Flexible Thinking – allows your child to adjust to the unexpected.

Working Memory -helps your child keep key information in mind.

Self-Monitoring – allows your child to evaluate how you’re doing.

Planning and Prioritizing – help your child decide on a goal and a plan to meet it.

Two of the major ADHD researchers involved in studying EF are Russell Barkley, PhD, and Tom Brown, PhD, have also their own version of key executive functions[7]:

Barkley breaks executive functions down into four areas[7][8]:

Nonverbal working memory

Internalization of Speech (verbal working memory)

Self-regulation of affect/motivation/arousal

Reconstitution (planning and generativity)

Brown breaks executive functions down into six different “clusters.”[7][9]

Organizing, prioritizing and activating for tasks

Focusing, sustaining and shifting attention to task

Regulating alertness, sustaining effort and processing speed

Managing frustration and modulating emotions

Utilizing working memory and accessing recall

Monitoring and self-regulating action

Hmm.. they’re like the soccer team. Each member must function and cooperate well to win a game.

(C) Cartoon Network. Key executive functions are like a soccer team.

With executive function in sync, learning is much easier for a growing child up to his adulthood.

How executive function develops?

A range of tests measuring different forms of executive function skills indicate that they begin to develop shortly after birth, with ages 3 to 5 providing an important window of opportunity for dramatic growth in these skills. Growth continues throughout adolescence and early adulthood; proficiency begins to decline later in life.[10]

Image courtesy of Harvard University/NIH Toolbox project. This graph shows executive function development and proficiency across the life span.

Where in the brain is executive function?

Historically, the executive functions have been seen as regulated by the prefrontal regions of the frontal lobes,[1] but a review found indications for the sensitivity but not for the specificity of executive function measures to frontal lobe functioning. This means that both frontal and non-frontal brain regions are necessary for intact executive functions.[1]

Neuroimaging and lesion studies have identified the functions which are most often associated with the particular regions of the prefrontal cortex.[1][11]

The prefrontal cortex has its parts where specific executive functions are:

The dorsolateral prefrontal cortex (DLPFC) is involved with “on-line” processing of information such as integrating different dimensions of cognition and behaviour.[12] As such, this area has been found to be associated with verbal and design fluency, ability to maintain and shift set (mental ability to switch between thinking about two different concepts, and to think about multiple concepts simultaneously), planning, response inhibition, working memory, organisational skills, reasoning, problem solving and abstract thinking.[11][13]

The anterior cingulate cortex (ACC) is involved in emotional drives, experience and integration.[12] Associated cognitive functions include inhibition of inappropriate responses, decision making and motivated behaviours. Lesions in this area can lead to low drive states such as apathy (absence of feelings), abulia (lack of will or initiative) or akinetic mutism (patients tending neither to move (akinesia) nor speak (mutism)) and may also result in low drive states for such basic needs as food or drink and possibly decreased interest in social or vocational activities and sex.[12][14]

The orbitofrontal cortex (OFC) plays a key role in impulse control, maintenance of set, monitoring ongoing behaviour and socially appropriate behaviours.[12] The orbitofrontal cortex also has roles in representing the value of rewards based on sensory stimuli and evaluating subjective emotional experiences.[15] Lesions can cause disinhibition, impulsivity, aggressive outbursts, sexual promiscuity and antisocial behaviour.[11]

When children have opportunities to develop executive function and self-regulation skills, individuals and society experience lifelong benefits. These skills are crucial for learning and development. They also enable positive behavior and allow us to make healthy choices for ourselves and our families.[10]

When children have opportunities to develop executive function and self-regulation skills, individuals and society experience lifelong benefits.

We usually have this executive function taken for granted. But for people in neurodiversity, their executive function is broken or impaired, inhibiting their normal functioning.

What happens if executive function is impaired?

If executive functioning is working well and the task is fairly simple, the brain may go through these steps in a matter of seconds. If your child has weak executive skills, though, performing even a simple task can be challenging. Remembering a specific word may be as big a struggle as planning tomorrow’s schedule.[5]

When executive functioning is impaired, all of its functions cannot be done or sustained. Hence, this is called executive function disorder (EFD) or executive dysfunction.

If your child has executive functioning issues, any task requiring these skills could be a challenge. That could include doing a load of laundry or completing a school project. Having issues with executive functioning makes it difficult to:

Keep track of time

Make plans

Make sure work is finished on time

Multitask

Apply previously learned information to solve problems

Analyze ideas

Look for help or more information when it is needed[5]

To explain this further, let’s include the 8 key executive functions and how they become impaired when executive function is broken:

Impulse Control – Kids with weak impulse control might blurt out inappropriate things. They’re more also likely to engage in risky behavior.[6]

Emotional Control – Kids with weak emotional control often overreact. They can have trouble dealing with criticism and regrouping when something goes wrong.[6]

Flexible Thinking – Kids with “rigid” thinking don’t roll with the punches. They might get frustrated if asked about something from a different angle.[6]

Working Memory – Kids with weak working memory have trouble remembering directions – even if they’ve taken notes or you’ve repeated them several times.[6]

Self-Monitoring -Kids with weak self-monitoring may be surprised by a bad grade or negative feedback.[6]

Planning and Prioritizing – Kids with weak planning and prioritizing skills may not know which parts of a project are most important.[6]

Task Initiation – Kids who have weak task initiation skills may freeze up because they have no idea where to begin.[6]

Organization -Kids with weak organization skills can lose their train of thought – as well as their cell phone or homework.[6]

EFD is relatively common in neurodiversity and less so in neurotypical people and can affect people of any degree of intelligence and capability.[16] Unfortunately, EFD is often mistaken as ADHD or LD (learning disabilities) by doctors (ADHD can have no EFD, just their hyperactive and inattentive problems). But despite giving learning therapies, children with EFD do not respond to them, thus mistaking them as lazy, unmotivated, stubborn or uncooperative. Usually, nothing could be further from the truth. They are working as hard as they can to keep pace with the demands in their lives.[16]

Very bad. Not only they will suffer in school and cause educational underachievement – suspension, dropping out of school, repeating a grade, but also they will have a high risk of becoming unemployed and socially isolated, increasing risk for mental disorders.

What causes EFD?

In most cases of executive dysfunction, deficits are attributed to either frontal lobe damage or dysfunction, or to disruption in fronto-subcortical connectivity. Neuroimaging with PET and fMRI has confirmed the relationship between executive function and functional frontal pathology.[2][17] Certain genes have been identified with a clear correlation to executive dysfunction and related psychopathologies.[17] Not surprisingly, plaques and tangles in the frontal cortex can cause disruption in functions as well as damage to the connections between prefrontal cortex and the hippocampus.[17][18] Another important point is in the finding that structural MRI images link the severity of white matter lesions to deficits in cognition.[17][19]

The heritability of executive functions is among the highest of any psychological trait.[17][20] The dopamine receptor D4 gene (DRD4) with 7′-repeating polymorphism (7R) has been repeatedly shown to correlate strongly with impulsive response style on psychological tests of executive dysfunction.[17][21]

Image courtesy of The Telegraph. This is a messy table. Can be an EFD or just simply lazy.

What needs to be done for EFD?

Early assessment needs to be done to avoid problems in school, work, and social relationships that could affect a person with EFD.

According to a local expert on EFD, Sarah Ward, M.S.,CCCSLP, of Lincoln, Massachusetts, one of the biggest complaints about children with EFD is, “They did it yesterday, why can’t they do it today?” For such children, however, the organizing pattern is not established in one pass; pathways must be developed through repeated practice. An important method of helping these kids is by teaching processing skills. Ward believes that this can be done most effectively through[16]:

Segmentation: Teaching (not telling) students how to break down a task into smaller, manageable parts.

Mental picturing: Teaching students to think through a situation in order to envision how a goal can be accomplished

Using visuals as a reinforcement.

Now, there is an application of these strategies in the following quotation from aane.org[16]:

Ward gives an example that uses these four techniques. A child was asked to set the table for dinner. She got stuck and overwhelmed in her attempts to do the task.

The child was helped to break down the task to a manageable level, in this case putting out four plates.

Once this was accomplished, the use of declarative language helped determine the next step. Rather than saying, “Okay, now put out the forks and knives” (imperative), the statement Ward made was, “Great, the plates are out. Now we’ll need something to eat the food with” (declarative).

In this one brief statement, the child was given specific positive feedback for what she had done (“Great, the plates are out” as opposed to the generic “Good job”), and was asked to assess the situation and figure out what came next.

Ward often uses photos or drawings to reinforce the concept being taught. In this case she used a photo of a correctly set table. It “conjured up the whole” and showed what it would look like if the table were set properly. Ward often uses stock images such as those found in Google Images (Ward even Googled Hamlet to show whatever images there were to help a student write an essay about the character!)

These concepts work equally well in school situations. As teachers we often say something like, “Take out your ruler and calculator and get ready for math.” Ward suggests that a better way to help students develop skills that will generalize to future situations is to say, “We’re going to do graphing now. How would your desk look? What is involved in graphing?” This teaches the student to become more self-directed by encouraging the development of self-talk, which Ward calls “notes to self.” The development of this kind of self monitoring is essential to effective, independent thinking and functioning.

Another crucial concept children need to learn, Ward says, is the “sweep and passage of time.” She explains that we teach kids to read the clock, but this has little to do with monitoring the passage of time. Ward uses a wall clock with a glass cover and actually draws on its surface with erasable markers to block off the amount of time that will be allowed for a task. In Ward’s estimation this concrete visual “pie shape” method of demonstrating the passage of time gives a sense of control and improves motivation, because “They can see they are succeeding.”

There are tests to diagnose EFD in people. Here they are:

Clock Drawing Test (CDT) – The Clock drawing test (CDT) is a brief cognitive task that can be used by physicians who suspect neurological dysfunction based on history and physical examination.[17]

The procedure of the CDT begins with the instruction to the participant to draw a clock reading a specific time (generally 11:10). After the task is complete, the test administrator draws a clock with the hands set at the same specific time. Then the patient is asked to copy the image.[17][22] Errors in clock drawing are classified according to the following categories: omissions, perseverations, rotations, misplacements, distortions, substitutions and additions.[17][23] Memory, concentration, initiation, energy, mental clarity and indecision are all measures that are scored during this activity.[17][24] Those with deficits in executive functioning will often make errors on the first clock but not the second.[17][23]

Stroop task – The Stroop task requires the participant to engage in and allows assessment of processes such as attention management, speed and accuracy of reading words and colours and of inhibition of competing stimuli.[17][25] The stimulus is a colour word that is printed in a different colour than what the written word reads. For example, the word “red” is written in a blue font. One must verbally classify the colour that the word is displayed/printed in, while ignoring the information provided by the written word. In the aforementioned example, this would require the participant to say “blue” when presented with the stimulus. Although the majority of people will show some slowing when given incompatible text versus font colour, this is more severe in individuals with deficits in inhibition. The Stroop task takes advantage of the fact that most humans are so proficient at reading colour words that it is extremely difficult to ignore this information, and instead acknowledge, recognize and say the colour the word is printed in.[17][26]

Wisconsin card sorting test (WCST) – The WCST utilizes a deck of 128 cards that contains four stimulus cards.[17][25] The figures on the cards differ with respect to color, quantity, and shape. The participants are then given a pile of additional cards and are asked to match each one to one of the previous cards. Typically, children between ages 9 and 11 are able to show the cognitive flexibility that is needed for this test.[17][27][28]

Trail-making test – This test is composed of two main parts (Part A & Part B).[17] The participant’s objective for this test is to connect the circles in order, alternating between number and letter (e.g. 1-A-2-B) from start to finish.[17][29] The participant is required not to lift their pencil from the page. The task is also timed as a means of assessing speed of processing.[17][30] Set-switching tasks in Part B have low motor and perceptual selection demands, and therefore provide a clearer index of executive function.[17][31] Throughout this task, some of the executive function skills that are being measured include impulsivity, visual attention and motor speed.[17][30]

What about the adult with EFD?

Just like the child/student with EFD, an adult who has it certainly has problems in working memory, task completion, and emotional regulation. An adult with EFD will struggle to sustain a regular job, run a household, and control her emotions as well as maintaining relationships.

For those emerging adults who are not competent in these life skills, their self-image and self-esteem suffer tremendously. They feel debilitating shame and self-recrimination. They try to hide their incompetence, not asking for help, soon they are overwhelmed with dirty laundry, broken appliances, messy refrigerators, and unpaid bills. For example, one young man is fully capable of showering, dressing himself, and making it to appointments, but he has never experienced independent living. He has not learned how to do laundry, budget his money, or set up utilities in a new apartment.

He feels great shame and self-contempt, as if he’s “supposed to know how” to do these things, even though he has not had a chance to learn. Instead of reaching out to those around him who can show him the way, he denies his needs out of humiliation and self-condemnation. Instead of asking for assistance, he laughs at the thought, stating he doesn’t need the help. At these moments, he feels utterly alone in the world, unable to request the help he needs because he thinks he should already know how to do everything. Even when those around him offer support, he brushes it off, later resenting that no one is there to support him. The idea of successfully living an independent life seems hopeless.

To a parent, teacher, or boss, what looks like laziness or irresponsibility may actually be executive functioning deficits, which are neurological mechanisms tied to specific brain functions key to development at this age. The parent sees the son who isn’t showering and is distressed, concludes that he is lazy or doesn’t care about his appearance, when it is really a deficit in the executive function of “initiation.” A teacher observes a student who forgets to turn in homework all the time and concludes that student is irresponsible when, really, it is a deficit in “planning.” A boss sees an employee who gets stuck on simple tasks as “dumb” when, in reality, it is a deficit in “problem-solving.”[32]

Very embarrassing, isn’t it?

That’s why identification of a executive function disorder is important in order to manage its problems so the person affected will have less problems in his everyday life. Managing EFD in adults is similar to therapies done on children, but on an adult level.

If you are a person with EFD or suspected EFD, follow the given intervention above of segmentation of tasks to avoid confusion. Also, try to choose a job with less “procedural” tasks, i.e., musician versus nurse (where a nurse has a lot of “procedural” tasks that needs very intact executive function; musicians do not need to have that as they are only require to repeatedly play a musical instrument plus memorize a particular piece).

Remember, next time you encounter a”lazy” child or “disorganized person,” maybe you can suspect that he has impaired executive function, which most of us would normally take it for granted.

To conclude this, let’s take an excerpt from all-gifted.com:

Before that goes away, we as parents must work hard so that our children at least keep up with the work required of them. We must chip in to help, teach time management and organization skills, and look out for tools to phase them into self-reliance.[33]

That’s right. The earlier the identification and assessment, the better.

So if you have a child who is so gifted in other areas that his executive function falls behind and into judgmental eyes, would you crucify him for what he lacks, or would you patiently work and put things in place for him until he finds his next champion or develop his own planning methodologies and coping strategies?[33]